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A VET'S GUIDE TO LIFE

Pulling back the curtain on veterinary life since 2008.




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THURSDAY, JANUARY 26, 2017


REALISTIC DOG MODEL TO REPLACE CADAVERS


I came across this article last year, but never got around to writing about it.
 It's pretty cool!


A company, SynDaver, has created realistic dog models for veterinary schools.
 The intent is to replace cadavers used in veterinary studies, as well as live
animal surgeries.  Here is a quote from the article:


The synthetic cadaver is made of water, fiber and salt. Each cadaver is
anatomically correct and features lifelike fat, fascia planes, bones, muscles,
ligaments, joints and all body systems.
 
The skinless dog not only mimics the feeling of living tissue but breathes, has
a heartbeat and can be programmed to simulate various diseases and medical
complications. The skin even bleeds when surgical cuts are made, since the
cadaver has a circulatory system.










I would be very curious to try one of these out myself!  I love the idea, and
agree with the concept of trying to reduce procedures done on living animals.
 However, a surgery on a model, no matter how sophisticated, can't duplicate the
feel and circumstances of a living animal.  Is it close enough to be comparable
for training purposes?  I don't know, and I'm hopeful that it would be.  


Similar models are used in human medicine, so this may be something that would
be very useful for veterinary students.  If nothing else it's a great step in
the right direction, and shows how far technology has come, as well as where it
can help us in the future.

Posted by Chris Bern, DVM at 8:06 PM





MONDAY, JANUARY 23, 2017


THE GROWTH OF CORPORATE VETERINARY MEDICINE


A few weeks ago a small bombshell hit the veterinary community.  Mars, Inc.
announced that they were buying Veterinary Centers of America (VCA) and their
subsidiaries.  And this has fueled strong discussions and great concern in the
profession in the US.



To anyone not in the veterinary field the significance of this will likely be
lost so let me give some details and perspective.  Mars is the largest privately
owned company in the world and spans every continent. The company was started by
the Mars family and is still  run by that family, now in the fourth and fifth
generations after the founders.  Most people know them for their candy products,
such as M&Ms, Snickers, and other classics.  But over time they have bought up
many other companies, gaining access to their product lines.  To get an idea of
the incredible number of human and animal products they make, head over to the
Wikipedia entry on them.



Several years ago Mars bought all controlling interest in Banfield Pet
Hospitals.  This is a national veterinary chain, primarily based in PetSmart
stores, currently with over 900 locations across the US.  Last year Mars bought
BluePearl, a chain of specialty and referral clinics with over 50 locations, and
Pet Partners, a smaller corporation with over 50 vet clinics.  This month they
announced the purchase of VCA, which gives them nearly 800 clinics around the
country.   VCA also owns Antech Diagnostics, which is the largest veterinary
diagnostic lab in the US, serving a majority of veterinarians across the
country.  By the end of this year the Mars company will own nearly 2000
veterinary clinics as well as a huge diagnostic laboratory.  This is unheard of
and unparalleled in the history of veterinary medicine.



Historically a veterinary clinic has been owned by one doctor or a small group
of partners.  Over the last 20-30 years we have seen a rise of large
corporations such as Banfield and VCA, as well as smaller regional or local
corporations that may have anywhere from a dozen or two to a hundred or more. 
While the two biggest companies gain most of the publicity and concern, there
are many other smaller corporations out there (such as Pet Partners, now owned
by Mars).  But even with these companies the vast majority of veterinary
practices are owned as a single location and not a conglomeration.  Though Mars
will own a large number of clinics, larger than any other company in history,
they will control only about 6% of the practices in the US. 



In my experience veterinarians as a whole are very strong-willed, independent
people.  When I was going through school we knew that the majority of the people
graduating would go on to be owners or partners of a small animal clinic.  This
is still the case, but the patterns are changing.  Historically it was almost an
expectation that after practicing for a while a vet would buy into that clinic
or open their own.  But the younger generations of vets are less interested in
being business owners, and are more interested in flexible schedules and quality
of life outside of work.  The younger vets simply don't want to have to work the
60+ hours per week that generations past saw as normal.  I can't blame them. 
This shift is in part due to generational differences, but are also because the
profession is skewing highly female and many of these doctors want the freedom
to raise families without having to worry about running a business.  While there
are certainly still many vets who want to have a clinic of their own, and can
run them successfully even with kids and a spouse, we are seeing fewer vets who
want to go this route.



To these younger vets a corporation can seem very appealing.  They can get a
good salary, have a degree of flexibility with their work schedules, and simply
never have to worry about taking out loans (on top of the ones from school) to
start a clinic.  They get to simply be a vet for their life, which is all that
many of them want.  A corporation, especially the larger ones, gives them the
structure and freedom to have this lifestyle.



I've been following discussions on the Veterinary Information Network (VIN) and
other sites.  While there are some people who shrug and don't care about the
growing Mars hold on our profession, there are others who are significantly
worried about it.  Here are some comments I've seen online.



"My big concern with the acquisition is this: Who owns our profession now? I
would argue that as of the drying of the ink on the Mars VCA deal veterinarians
no longer have a profession. Now Mars Co which is in essence just a very wealthy
family (who so far as I know are not veterinarians) are going to be
substantiatively guiding our profession. We are now going to take our
professional direction from the kings of candy. We have entered the new future
of veterinary medicine not as a profession but rather as a trade in which each
veterinarian is now a production unit." 



"Essentially, if there is one player who owns a significant portion of the
market, they will be able to dictate the conditions of how you practice, what
your treatment recommendations would be, what products you use, and who you
refer to."

"There will be little room for dissent once the vertical integration is
established. How are you going to say no when the other 75% of practices in your
town are effectively owned by the same entity? There has always been the ability
to move to another practice if you did not agree with management or philosophy
of your current place of employment. This luxury may not be as available in the
future."

"I would like to see my clients have choices. I would like to have choices about
where I am able to refer clients for advanced care. Unfortunately the only
emergency facilities around me for hundreds.....yes hundreds of miles are VCA or
are in the process of becoming VCA."

"I don't like feeling like I'm speaking for everyone, but in my case it doesn't
matter that Mars/Banfield bought VCA - it could be VCA buying Banfield and Blue
Pearl. It could be Apple, or Google, or GM, or Lockheed Martin buying VCA and
Banfield. My problem is not with who is doing the buying, but the buying and
consolidation under one (albeit big) roof is happening - and veterinarians
aren't going to be driving the company."  

"While it may be true that Mars will control less than 10 %of the veterinary
hospitals in the nation what I see on a local scale is unmitigated Monopoly."

"While I cannot discuss my prices with my local practice owners, the VCA's and
Banfields are more than able and in my experience willing to price fix a
geographic area. Combine that with limited exit strategies to sell my practice,
the increased cost of drugs, health insurance etc on a unit basis due to
economies of scale ......I can tell you I am concerned.....very concerned. I can
tell you that when individuals ask me if I would make the same decision to
pursue veterinary medicine as a career today as I did twenty some years
ago....as a tech and then as a doctor. The answer is no...emphatically no."



"I find the corporate takeover (though limited at this time) of our profession a
tragic occurrence for future Veterinarians. As corporations control more of the
profession we will become more of a cog in the machine and easily replaceable. I
always looked at practice ownership as the means to improve my financial
position in life as owners do make more money than employees. If this trend
continues that will no longer be an option for future veterinarians to better
their position and, at least to me, it seems to severely limit their financial
future. Is Veterinary medicine doomed to become the "second" family income and
no longer an option as the primary family income?"



 But not everyone is so "doom and gloom".

"In the 10+ years I've been on VIN I've been reading threads about the certain
and imminent doom of the profession at the hands of Banfield and VCA. Here we
are 10 years later and they still have only 6.5% of the market COMBINED. I think
we have the best of both worlds as a profession. The profession has a enough
economic upside to be seen as a desirable asset to large companies, yet the vast
majority of it is privately owned."

"Mars is not the boogey man, they are a large company interested in profit that
pursues other successful companies within their areas of interest and expertise.
Personally I think smaller private equity firms are going to have a bigger
impact on our profession's ownership over the next 20 years than one corporate
player. No one talks about those deals though because they are invisible. (the
clinic's name doesn't change)."

"I think we're all going to be just fine, and I say this a practice owner
surrounded by corporate practices. They were private clinics before (with the
exception of a Petsmart Banfield) and now that they are corporately owned that
just provides an extra differentiator ("locally-owned practice") for me that
wasn't there before. In any case it's counter productive to think that
veterinary practice owners-- uniquely among American small business
owners--ought not to have to contend with corporate competition."

"A few years ago at a dinner party at a friends house, another guest was some
big, mucky muck who ran in house seminars for Mars. It was his only job; setting
up and conducting management seminars all over the country for Mars. He had a
second home in Italy, so I gathered it paid well. We sat next to each other over
dinner. He was fascinating and I gained a great deal of respect for how Mars
operated. This might have been before Mars bought Banfield....I want to say Mars
was always a financier of Banfield....but this would have been around 2002-3.
Anyway, I've always been impressed with whatever mars has done. They look like
they know what they're doing."

"It's easy to blame Banfield because it's corporate and ubiquitous, but as said
above, you will find plenty of questionable things happening at private
practices as well - but it seems like if a doctor in private practice does
questionable things, it gets blamed on the doctor. If a doctor does something
questionable at Banfield, then Banfield gets blamed - not the doctor."

As you can see there are some pretty passionate views on these events.  Many
people are genuinely worried for themselves and the profession as a whole, and
some see this as the worst thing to have ever happened.  Others simply aren't
worried.

So what's my take on this?

First, I certainly don't subscribe to the opinion that all hope is lost and the
profession is ending.  I think that there are pros and cons to corporations
owning veterinary practices.  These companies often have better negotiating and
purchasing power which allows them to manage costs more easily and give higher
salaries and better benefits than a privately owned practice.  There is more
lateral and upward mobility for the veterinarians.  They provide some
consistency and guidelines for practicing vets.  But they can be limiting in
flexibility for an individual doctor.  Sometimes the leaders can be unfeeling
because they don't have a good understanding of day-to-day challenges.  Change
is often slow and difficult, unlike a private practice owner who can suddenly
decide to buy a new chemistry analyzer.

I firmly believe that no veterinary practice is going to be perfect for
everyone.  I've seen privately owned clinics that are far stricter on dress
codes, behavior, and medical choices than either VCA or Banfield.  I know that
vets who want their own practice or more independence will not be happy with a
corporate environment.  Doctors who only want to practice and never want to be
owners or partners will be happy to turn over all business responsibilities and
worries to someone else.  A place that is a perfect fit for one person may be
only manageable for another and be complete misery for someone else.

Our profession is changing, and doing so pretty rapidly.  The demographics of
who attends veterinary school has altered dramatically in the last 30 years. 
Within the last 60 years we have moved more and more from a rural to a suburban
and urban outlook, with an increasingly smaller percentage of new graduates
choosing to go into large animal medicine.  The growth of the internet has seen
a noticeable shift towards clients purchasing medications and preventative
products online rather than buying them from the local vet.  I would say that
the internet has been a bigger problem for all kinds of businesses than any
large corporation has.

In the US corporately owned veterinary practices aren't going away.  But I don't
see them becoming so large and all-encompassing that they wipe out the
traditional privately owned practices.  Just as there is room for chain
restaurants and "mom and pop" ones, there is room for private and corporate
veterinary practices.  In fact, I think having both available gives
veterinarians more choices about where they want to work.


Posted by Chris Bern, DVM at 7:58 PM





FRIDAY, JANUARY 20, 2017


THE HIGH COST OF BECOMING A VET


I haven't written about veterinary education costs in quite a while, and
unfortunately there has been no improvement in the situation.  It is still
extremely expensive to become a vet and salaries still remain very low,
resulting in some significant challenges and hardships as young, new vets
struggle to try and repay their loans while maintaining a moderate lifestyle.
 
Dr. Julie Funk, an Associate Dean and Professor at Michigan State University,
recently wrote an article about this issue.  Here are some choice quotes. 
 
"A 2013 national survey of DVM graduates found the average debt for students was
as high as US$162,113. This is similar to the average educational debt of
$180,723 accrued by physicians in 2015. However, physicians have much higher
lifetime earnings than veterinarians, making it easier for them to manage their
debt.
 
It is true at the beginning of their careers, salaries for veterinarians and
physicians are quite comparable: Veterinarians get, on average, a full-time
starting salary of $67,136 annually. Physicians, who pursue residencies for
advanced specialty training under supervision, soon after graduation, earn an
average first-year salary of $52,200.
 
However, this changes over the years. The lifelong earning potential of
physicians improves significantly in comparison with veterinarians. Over a
period of time, the overall median salary of a physician gets to $187,200,
whereas that of a veterinarian remains at about $88,490.
 
The situation is worse for women. Female veterinarians, on average, will not
even break even on their educational investment until they are well past the age
of 65 (or older)."
 
That last statement is particularly troubling since in the US 75-80% of
veterinary classes are female.  How bad is it that they aren't likely to even
break even on their education costs until they retire around 40 years later???
 
The future for veterinary students is not promising, as Dr. Funk points out
later in the article.
 
"As a result of the growth in the colleges of veterinary medicine, more seats
are available. (What is decreasing, however, is the applicant-to-seat ratio.)
Two new colleges are seeking accreditation, while the existing ones are boosting
class size. This expansion is happening in the face of the 2013 Veterinary
Workforce Study that estimates that there is an excess of veterinary labor
nationally.
 
High tuition, low wages, an oversupply of veterinarians and more seats to study
veterinary medicine are strong signals of a veterinary education market bubble."
 
What these facts indicate is that's there are more people entering the field,
yet on a national average there are more vets than are needed.  Colleges are
increasing the number of students they accept and new schools are being built,
yet there is no need to expand the number of newly graduated veterinarians.  In
the end this may very well result in a glut of veterinarians, which could cause
lower wages as employers can pick new hires who are willing to work for less and
those new hires will accept it because there are fewer job opportunities.
 
For most of us veterinary medicine isn't just a job, it's a calling.  I started
wanting to be a vet when I was nine years old, and that's typical of most of us
in the profession.  When your heart desires something so strongly it becomes
hard to resist and look at the reality of the situation. 
 
The veterinary colleges and national organizations have had numerous
discussions, debates, panels, and reports over the last 10 years or so, but so
far all I've seen is more of the same information and confirmation of previous
information.  For many years we keep seeing the outcome of these various studies
as "Yep, debt is worse, salaries are no better, the problem is literally a
crisis, and it's not getting better in the near future."  Well, we know that by
now.  What we're lacking in the profession is a consensus of how to solve this
crisis.  Maybe we should be shrinking class size rather than expanding them. 
Maybe we should be closing schools rather than opening new ones.  Perhaps if
there were fewer vets entering the workforce we would see salaries rise as
competition increased. 
 
Some have suggested looking at a model where an undergraduate and graduate
degree are obtained at the same time.  Currently virtually everyone first spends
an average of four years obtaining a Bachelor's degree, then another four years
for their veterinary doctorate.  Much of that undergraduate education is spent
on classes intended to make someone well rounded but that doesn't have anything
to do with the career.  I took two semesters of calculus in college, but I
couldn't tell you what I learned or how it might be useful.  I can guarantee
that in 20 years as a vet I've never had any cause to use the information in
those classes.  As much as I enjoyed my literature and history courses they
really have never applied to my career.  If the first 2-3 years of college were
strictly pre-veterinary courses and then the last 3-4 years were on veterinary
education itself you could reduce the time to become a vet by about two years. 
That means two years of tuition and other expenses that you don't have to pay,
and don't go into debt over!  Make the education year-round without summers off
and some have speculated that you could become a vet in as little as five
years!  There are pros and cons to this proposal, but it's one being
considered.  Unfortunately I don't think it would be accepted by the majority of
veterinary colleges or the veterinary licensing entities, so something like this
in the US is probably a long way off.
 
I know that it's very depressing and disheartening, but I honestly can't
recommend this as a good time to go into veterinary medicine.  Student debt load
is quickly increasing while at the same time starting salaries are stagnant or
even decreasing.  These horrible facts are not likely to change in the next few
years.  I know that young people with a passion to be a vet will read these
words and potentially despair.  Yes, the future is a little bleak if you haven't
actually become a vet yet.  If someone still chooses to follow that dream I
would strongly encourage them to be VERY good at budgeting, realize the huge
amount of debt they will have coming out, and even consult a professional
financial planner.
 
I'm just glad I graduated 20 years ago when it wasn't nearly as bad as it is
now.
 

Posted by Chris Bern, DVM at 5:58 PM





WEDNESDAY, JANUARY 18, 2017


POISONOUS PLANTS TO KEEP AWAY FROM PETS


Recently ProFlowers.com contacted me about an infographic they have on their
website which lists nearly 200 poisonous plants, how toxic they are, which parts
or toxic, and which species to keep away from them.  Honestly, this is one of
the best summaries I've ever seen, so I'm sharing it here.  Please pass this
around to your friends and other pet owners.  If you're having a hard time
viewing it, click on the original link above.









Posted by Chris Bern, DVM at 9:11 PM





SATURDAY, JANUARY 14, 2017


WHAT TO DO WITH FIV POSITIVE CATS


A few weeks ago I received the following email:
 
We just had a stray cat euthanized because he had FIV and the vet recommend this
because we couldn't bring him in with out cats and we couldn't keep him outside
to spread the disease and he would have been hard to adopt out because of the
FIV and he was a fighter.  He was sweet to us but had been in fights with area
cats.  I am feeling extreme guilt over this.  Did we do the right thing?  It
seems like we did what was best for us and maybe not the cat.  I am devastated
and am feeling like a horrible person.
 
I've had this exact same situation come up a few times in the past.  It's never
easy to handle, and always a tough decision.
 
Feline immunodeficiency virus (FIV) is very similar to HIV in humans.  In fact,
some veterinary researchers on the disease have collaborated with HIV
researchers and vice-versa.  The virus can lay dormant in a body for years and
become active at any time.  Once it activates and affects the body it proceeds
very similar to AIDS in humans, suppressing the immune system, lowering white
blood cell counts, and making the patient much more susceptible to infections. 
When the virus starts along this path there really isn't anything we can do.  We
don't have a wide range of antiviral drugs in animals like there are in humans,
so essentially a diagnosis of FIV is a ticking time bomb and an eventual death
sentence.
 
Once a diagnosis of FIV is made, the cat may live a few more weeks or several
more years.  There is no way to predict what their lifespan will be.  But we
know that they won't live as long as an uninfected cat and will be more prone to
health problems.  At some point in the cat's life the virus will lead to its
death.  Unfortunately there is currently no treatment or cure for FIV, so once a
cat has it they are infected for life and are at risk of spreading it to other
cats.
 
So what do you do when a cat is diagnosed?
 
I 100% feel that these cats need to be isolated indoors.  If you allow them to
continue to roam outside they are most likely spreading the virus to other cats
and therefore giving more animals a death sentence.  When they are "fighters" as
in the email above this is much more likely, and every time it fights with
another cat it is probably passing along FIV.  If a cat can be kept indoors they
can still live a good life until they become seriously ill, and I've known many
FIV positive cats who have lived more than five years indoors before succumbing
to the disease.  So I don't think that a cat with FIV but no symptoms
automatically needs to be euthanized.
 
Some people can't keep the cat inside for various reasons.  Maybe they have
other cats, and there is certainly a risk of passing FIV to the ones that person
already has.  Some outdoor cats won't tolerate being kept inside and will be
destructive with scratching and spraying.  So there are certainly situations
where that cat can't be kept in the home.
 
What do we do then?  We can't keep the cat inside, but we can't let it outside
to be a vector of infection.
 
As harsh as it may sound, the best option is often humane euthanasia.
 
Stop and think about it.  Is keeping that cat alive worth having a dozen more
cats develop FIV?  While it sounds pretty cold and unfeeling I do believe in
this situation we have to look at the greater good and the potential for the
most harm.  It is a bit of an ethical dilemma, but I personally think that
gently ending the infected cat's life to prevent infection in 20 other cats is
justifiable.  It's not easy, but it's the best option in a bad situation.
 
With a stray cat kept outside a person also not know when that animal becomes
sick.  A cat with active FIV may slowly die a miserable death somewhere in the
woods or under a porch.  Do we leave them outside to have this eventually
happen, or do we give them a quick, peaceful death before they suffer?
 
I have euthanized a few FIV positive cats in the exact situation described in
the email.  I haven't enjoyed it but I also haven't felt guilty about it
afterwards.  I don't think any pet owner should feel bad about making this
choice, even if it's not ideal.  In the words of Spock in Star Trek: The Wrath
of Khan, "The needs of the many outweigh the needs of the few, or the one."
 
 

Posted by Chris Bern, DVM at 6:36 PM





WEDNESDAY, JANUARY 11, 2017


PREDATOR BIRDS AND SMALL DOGS


Here's a question that in over eight years of blogging I haven't been asked!
 
We saw a bald eagle fly over our house the other day.  We've also seen hawks and
owls.  My concern is our 13 lb dog's safety.  I was wondering if she wore a
piece of clothing outside if that would somehow make her look less like an
animal they would want to pick up.  I was just looking online and found this
page that mentions different products that are on the market.  Do you know if
any of these products are helpful?  At the end of the article it said eagles can
only pick up 4-5 lbs but other places I read much larger.  Would love to know
your thoughts.
https://www.adn.com/voices/article/alaskan-invents-flashy-coats-safeguard-tiny-
dogs-predators/2016/05/16/
 
When you think of a large raptor such as a hawk or eagle, you wouldn't think of
them as a potential concern for your pets.  After all, that's just Hollywood,
right?  You might think of it happening in a movie such as The Proposal (Ryan
Reynolds & Sandra Bullock) but not in real life.  Isn't it a myth?
 
I'm sorry to say that it's not.  While rare, birds of prey will occasionally try
and take off with a small dog.  I've had at least one client who lost a small
dog to a hawk.  So this is one that is definitely not a myth.
 
Bald eagles prefer fish over small mammals, but other kinds of eagles may have
more variety in their diet so it depends on what is native to your area.  Hawks
and owls do prefer small mammals, but will eat just about anything they can get
their claws on.  Since some of the larger raptors feed on rabbits, which can
weigh 4-6 pounds or more, a dog about that size certainly isn't safe.  I don't
have information on exactly how much weight a large predatory bird can carry, so
I'm not going to try and hazard a guess.  Keep in mind that they don't always
carry their prey away, and sometimes will kill and eat it on the same place.
 
What can a pet owner do?  The link above is pretty interesting, and I think
those products have some potential.  It's the first time I've ever heard of them
so I can't say whether or not they are effective, and I've never known anyone to
try them.  But if I had a small dog in this situation it sounds like it probably
wouldn't hurt to give it a try.  I would be slightly skeptical that a reflective
surface would always work, as I would imagine it being less effective on a very
cloudy day.  But the dog probably wouldn't look like prey with this on, so
that's a good thing.  If we're merely going by whether or not it looks like prey
to a raptor, you might achieve a similar effect with a colorful shirt or jacket
designed for dogs.
 
I do recommend being aware of the types of high level predators you might have
in your area, and for birds I would be cautious with any dog or cat under 15
pounds.  Ones under 10 pounds are more at risk.  If you know you have hawks,
eagles, and owls in the area I wouldn't let your dog go outside unsupervised,
and if you are in a very rural area you may consider only ever taking your dog
out on a leash.  A raptor isn't likely to try and kill or capture a dog when a
human is a few feet away, and if for some reason it did happen you'd  have your
dog on the leash, preventing the bird from flying away with him or her.
 
Those of you who have small dogs living in the same area as raptors, I wouldn't
panic.  These predators tend to prefer hunting without humans nearby, so most
dogs will be safe.  The risk exists, but even then the incidents of this
happening are very rare.  I still recommend taking some precautions because you
don't want to lose your dog to a situation like this.
 
 
 
 

Posted by Chris Bern, DVM at 6:32 PM





TUESDAY, JANUARY 3, 2017


CASE MANAGEMENT--ANXIETY, FEAR, THEN RELIEF


As I've mentioned before, most vets (and medical professionals in general)
really do worry about their patients.  I know that I do.  It's not uncommon for
me to fret over a case for days, especially if it's complicated or doesn't go
well.  Most of the time it's not my fault if things go bad, but I will worry
anyway because I'm my own worst critic.
 
One of the surgeries that I occasionally do is to correct "cherry eye".  For
those not familiar with the disorder, it is common in certain breeds (English
bulldogs, Shar-peis, Shih-tzus, and cocker spaniels are the most prone) and
results when the tear gland under the third eyelid becomes inflamed and
prolapses.  This causes a very obvious red, fleshy bump on the inside corner of
the eye.  If untreated there is a risk of chronic inflammation and damage to the
gland, which is responsible for the majority of tear production in the eye.  We
don't want to remove the gland because we would decrease the tear film and cause
dry eye problems.  The only real fix is surgery.
 
The most common method, and the one that I do, involves making an incision on
either side of the gland, forming a pocket under the tissues, placing the gland
within this pocket, and then closing the edges over the gland with sutures. 
Because the eye is so sensitive we use very small suture material, typically
about the thickness of a human hair or smaller.  While the surgery is typically
successful there is about a 20-30% "failure" or recurrence rate even with the
best surgeon.  The gland can re-prolapse because the suture breaks, the
technique was poor, the tissues fail to heal, or the inflammation is too
persistent.  Most of these reasons have nothing to do with the doctor, which is
why the failure rate is so high compared to other surgeries.
 
I've been performing this procedure for all of my nearly 20 years in practice
and have become pretty proficient with it.  Though I haven't specifically
tracked the numbers I would say that my recurrence rate is around 20-25%, right
within expectations.  Even so, I really hate it when one of my patients has a
relapse and I worry about whether or not my technique was correct or if somehow
I had failed as a surgeon which led to the failure of the surgery.
 
A couple of months ago I had that happen.  About three days after the surgery
the client called to say that it had prolapsed again.  I had her bring the dog
in and it looked like the suture had broken.  We would have to repeat the
surgery, and I said that I'd give her a $100 discount on the second
procedure due to the inconvenience.  Even though it didn't look like it was my
fault, I worried about it, and started to doubt myself.  I promised that the
next time I did this type of surgery I would be even more careful with my steps
and method.
 
That opportunity came in late November, with a shar-pei puppy who had both
glands prolapse.  When I did the surgery I was extra-careful about my incisions,
suture placement, knots, and generally everything that I could potentially
control.  The surgery went well and the patient looked great post-operatively. 
I was very hopeful that this one would be successful but I remembered my last
case.
 
About 10 days after the surgery I came in to work and there was a note for me
that the client had called and I should check the medical records.  My heart
dropped into my stomach and my first thought was "crap, one or both of the eyes
failed and relapsed".  I first saw the note around 8:15 am.  I didn't actually
look at the record until around 5:00 in the afternoon.  I had time to do so, but
was worrying about it the whole day.  I just knew that the client was calling to
say that it had happened again and perhaps be angry that it had done so.  I
always tell my clients two or three times what the rate of failure is, but that
doesn't always stop people from being upset when it happens.  I dreaded what I
would see in the notes.
 
As the day went on I started thinking and worrying even more, to the point of
being a bit sick to my stomach.  I doubted my abilities, and even started
thinking that maybe I should stop doing this particular surgery if I was going
to have a high recurrence rate.  Maybe I should be referring them out if I
wasn't going to get it right the first time.  Maybe I should never have
attempted it in the first place.
 
So I finally steeled myself, gritted my teeth, and pulled out the medical
records to read the notes from the previous day, preparing myself for the worst.
 
The client had called to ask if they could take the Elizabethan collar (e-collar
or cone collar) off.
 
That was it!  The client wasn't reporting any problems, only asking if it was
okay to stop using the e-collar!
 
I breathed a deep sigh of relief and called the client.  The dog was doing great
and the eyes were perfectly fine.  There was no sign of any problems or any
recurrence and his puppy was acting like nothing had happened to her.  We talked
about taking the e-collar off and watching her for any other problems.
 
I had worried for nothing.  I spent almost nine hours being anxious for no
reason whatsoever.  I had doubted my abilities when my personal success rate in
these cases is right in line with the profession.
 
That's not uncommon for me and many of my colleagues.  Most of us care deeply to
the point of doubting ourselves if something doesn't go exactly right.  It's
easy to forget all of the "good" cases when we are presented with a "bad" one. 
Many of us worry ourselves sick for things that are beyond our control.  Because
of this veterinarians have a high rate of clinical anxiety and depression.  It's
not easy having someone's beloved pet depend on you for their life and health.
 
 

Posted by Chris Bern, DVM at 5:27 PM



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ABOUT ME

Chris Bern, DVM I have been interested in science and animals all of my life.
When I was 9 years old I decided that I wanted to be a veterinarian. My first
job was at a vet clinic in 1984, when I was fourteen. I made a few detours along
the way, getting a Master's degree (MS) in 1991. However, in 1997 I did finally
graduate from Vet School at NC State. I've been practicing since then, with
another detour to teach college Biology. Besides all of that, I'm a born-again
Christian, attend Renaissance Faires, and am a big geek who is into comic books,
sci-fi, and fantasy. I've been a happily married man since 1998, and have two
wonderful children. View my complete profile



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